Frontotemporal Dementia in Older Adults: Diagnostic and Therapeutic Challenges

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Citation:

Pages 26 - 31

Authors:

Anna Yurchenko, MD, Maria I. Lapid, MD, and Keith A. Josephs, MD

Author Affiliations:

Dr. Yurchenko was a PGY III Psychiatry Resident at the time the manuscript was first written, but is now a PGY I Child and Adolescent Psychiatry Resident, Department of Psychiatry and Psychology; Dr. Lapid is Assistant Professor, Associate Program Director, Geriatric Psychiatry Fellowship, Department of Psychiatry and Psychology; and Dr. Josephs is Associate Professor of Neurology, Department of Neurology, Mayo Clinic, Rochester, MN.

Introduction

Frontotemporal dementia (FTD) is the second most common form of dementia in those who are younger than age 65 years, after early-onset Alzheimer’s disease.1 It is not a commonly recognized syndrome in clinical practice, and the lack of specific diagnostic criteria and wide variations in clinical presentation make determination of the syndrome difficult. We present a case of a 69-year-old female who had no prior psychiatric history but presented with gradual changes in personality and behavior, and gradual decline in functioning, of several years duration. Because of her age, the fluctuating and inconsistent nature of her symptoms, and oscillations of behavior from appropriate to inappropriate, she was diagnosed with a “functional” psychiatric disturbance as an attempt to distance herself from stressors. We describe the results of the evaluation that uncovered an FTD, review its pertinent clinical features and differential diagnoses, and highlight the importance of a thorough medical and neurologic evaluation of such patients. We will also note the implications of early recognition, prognosis, and treatment of FTD.

Clinical Vignette

Mrs. A is a 69-year-old Caucasian female whose initial symptoms 6 years prior were described as making socially inappropriate statements during conversations, word-finding difficulties, inability expressing herself, repeating herself, perseverating, rhyming, inability to make clear points when delivering speeches, and inability to keep up with usual work. Slowly and gradually, her physical and mental functioning deteriorated, with the development of apathy, lack of energy, difficulty sleeping, agitation, and progressive cognitive difficulties. Psychosocial stressors that coincided with onset of initial symptoms were the death of her mother and marital discord. Mrs. A was a prominent leader in her community who was referred to a psychogeriatric inpatient unit for further evaluation and management of changes in personality and behavior in the context of progressive functional decline of 6 years duration.

Medical history was significant for breast cancer in remission, past history of bilateral salpingo-oophorectomy and hysterectomy complicated by pulmonary embolism, and mild stage 1 lung sarcoidosis diagnosed 2 years prior but currently inactive. Psychiatric history was significant for a psychiatric hospitalization due to delirium 3 years prior, after which the patient subsequently had required supervision in her activities of daily living ever since. There was no history of alcohol or illicit drug use. Two prior neurocognitive testing and head imaging performed a few years earlier showed contradictory reports of “functional (conversion) neurologic disorder” and questionable dementia. Social history revealed a childhood with a verbally and emotionally abusive father, divorced parents, and educational attainment of less than 12 years. Mrs. A became successful later in life through active involvement in her church, which subsequently led to worldwide leadership activities. In the context of declining function (making tactless remarks in conversations, withdrawal from usual activities, isolation and spending most of the time at home, difficulties in giving public speeches, declining memory), she separated from her husband and began living with a friend who had assumed the primary caregiver role.

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